Medicare is a social insurance program financed by the United States government, providing health insurance coverage to people aged 65 and over. Currently, there are three separate Medicare coverage options which are referred to as Original Medicare, Medicare Advantage, and Medicare Supplement plans. Although similar in name, these three coverage options work differently to meet the health care needs of plan participants.
Original Medicare is a fee-for-service plan. In most cases, original Medicare is available to those 65 years of age or older, those with disabilities, and people with End-Stage Renal Disease. The service is divided into categories: Medicare Part A; and Medicare Part B. Medicare Part A covers inpatient care in hospitals including critical access hospitals and skilled nursing facilities (not custodial or long term care). It also helps cover hospice care and some home health care. Certain conditions must be met to obtain these benefits. Medicare Part B covers doctors' services and outpatient care as well as some other medical services that Part A does not cover such as the services of some physical and occupational therapists and some home health care.
Original Medicare provides very basic coverage for medical expenses, so members are still responsible for costs such as deductibles and coinsurance. Medicare Advantage and Medicare Supplement plans provide additional coverage for medical care. These plans give Medicare beneficiaries the option of receiving their Medicare benefits through private health insurance plans instead of through the original Medicare plan. For people that choose to enroll in a Medicare private health plan, Medicare pays the private health plan a specified amount every month for each member. Private plans are required to offer a benefit package comparable to Medicare's and to cover everything Medicare covers, but they do not have to cover every benefit in the same way. Medicare Supplement Plans are standardized with ten levels of coverage from which to choose. These plans are often referred to as “MediGap Insurance.” In contrast, Medicare Advantage plans offer more coverage options as they are not standardized and vary greatly from plan to plan.
Medicare Advantage plans are often times referred to as “Part C” plans. A private company wishing to offer a Medicare Advantage plan in a given county must create and submit a filing package for submission to CMS for approval. There are annual deadlines for the submission of these filing packages, also referred to as Part C applications. Critical in the Part C applications are data compilations known as Health Service Delivery (“HSD”) Tables. HSD tables contain information representing provider network adequacy on a county level. All provider data supplied on HSD tables is carefully reviewed by CMS and is a key factor in the acceptance or rejection of Part C applications. HSD tables permit CMS to determine whether a proposed Medicare Advantage plan meets the Medicare requirements mandated by the federal government.
Historically, the compilation of HSD tables has been a painstaking process. Because of the deadlines set on the filing of Part C applications, completing the detailed HSD tables on time for incorporation into the applications has been an extremely hectic task. There is a need in the art for a computerized system for the accumulation, alteration, and review of HSD table data.
One exemplary embodiment comprises a computerized system comprising at least one database storing health care service provider data and one or more servers where the one or more servers are adapted to receive health care service provider data from a remote computer, send the health care service provider data to the database from storage, receive a request from a remote computer to view health care service provider data that meets selected search parameters, retrieve health care provider data from the one or more databases in accordance with the selected search parameters, and transmit the health care service provider data to the remote computer for viewing. In some exemplary embodiments, the one or more servers sends the health care service provider data to the remote computer where it is populated into a worksheet displayed by the remote computer. In a preferred exemplary embodiment, once the health care service provider data is displayed by the remote computer, a system user may review the data and cause amendments to be made to the data stored in the database. In one example, a system user causes changes to be made to data stored in the database by completing an amendment request form that is generated by the system, saving the amendment request form, and then emailing the amendment request form to a reviewing body that sends the amended data to the database.
In some exemplary embodiments, one or more servers of the system runs a set of integrated tools that permit system users to view health care facility and health care practitioner data on a remote computer, cause amendments to be made to the data stored in the database, add health care facility and practitioner data to the database, review health care provider data that has been stored in the database in the format in which it will be filed with CMS (a “final file format”), approve displayed final files for filing, and analyze the health care provider data within final files to determine whether it satisfies CMS requirements.